Placement of Three Bicon SHORT® Implants in a Ridge Split

Hello and welcome to today’s webcast from Bicon. We’re coming to you from the Bicon Institute and the implant dentistry center in Boston. On the left side, we will, open a very conservative flap. We will perform the split and place, three implants. On the left side, the mesial most implant, the one in the location, of the first bicuspid, is going to go into the socket of the recently removed non restorable bicuspid. We will start by making the incision at the first, or excuse me, it is actually the first bicuspid, you’re with me there. And then in the area of the split, we’re going to make the same incision right into that crestal cut. And we will feel any pain. That tissue as as expected is very friable. It’s only two week old extraction. So what we will do is try to keep as much of it as possible. It will we will now, in the end, use a collagen plug to close over it. Okay? You feeling any pain? No? Okay. Suction right there. And no release toward the buccal in this case. Just the extent straight posteriorly will give us enough of leeway to be able to place that. And this is the only flap we will do. So the lingual plate is exposed somewhat. Alright. You see the top of the crest and you see the cut. You see the corticotomy cut right there. So what I’m trying to do is to see if this bone flap will mobilize just with torquing with curette. Sometimes that’s all that we need. I want to take a cottle chisel and split it, taking a small surgical mallet. Okay. So I can feel that the bone is starting to give. You won’t have a significant difference in the sound it makes, but you will start seeing that the actual bone plate is moving, and you want it to move as a unit. My goal is to place short implants in here, six millimeter long. No more is necessary. Are you okay, love? Good. That’s it. Okay. So now we’ve mobilized it. So you can see the whole plate is moving. Okay? Osteotomy will be at a depth of roughly, eight millimeters from the crest, and we are right about there now. That better? Okay. And now if you go deeper, it’s okay. Just don’t seat the implant as deep. K. Zero degree paralleling pin in the first bicuspid. Okay. We’ll use that to help us get into that osteotomy. And I don’t want to touch the bone at the crest. So if it’s touching the bone, the bone has not moved out enough yet. So we’ll take the curette again and move it back out. The idea is we’re gonna bypass that split bone, immediately drill into the basal bone. Okay. Good. That’s it. There you go. So one of the ways I also wanna be sure we’re at the correct, level is to palpate. I feel the bone vibrating but not being cut. Alright? Good. K. One, two. This, unfortunately, now is gonna get in my way for me to to drill. So I have to remove them. But first, I’ll just make a mental note where the next implant has to go, and it’s gonna go right near that little notch in the bone posteriorly if you see it. Right here. You okay? More water. Here’s one, two, and three. Okay? This one is easy because it really hasn’t tipped anything yet. It’s still the fleshy part of the socket suction. Notice the difference in speed and this is why you don’t need and incidentally also notice how the buccal plate is moving in unison. The key here is to find the initial osteotomy at the base of it. Feeling that a little bit? Okay. After the three and a half, I will use the hand reamers mounted on the adapter. And now we’re starting to engage the sides of the socket. Okay. Great. The key here is not to allow that flap to get caught on the edge as it can be peeled off of its blood supply. There’s a floor for this one, stay away please, and a lingual wall, exactly what we think we have. And there’s also a floor lingual wall. Floor lingual wall. We swap and now we have a floor and a buccal wall that has a slight step but no fenestration. Same here. Okay. Alright. This is the first bicuspid. It’s almost finished. Stay away. Alright. Bear with me, doing fine. Good. And now we’re in. Bear with me. I’m almost there. There. That’s lovely. Okay. So that’s the four millimeter. There we go. K. Thick. Alright. Let’s finish up this guy here. Bear with me. Know this is gonna be this is the last one. Okay? Bear with me. Doing awesome. Doing great. Okay, Sandra. Good. That’s it. K. Stay away, Joe. I need to make sure that we have the all of the shavings of bone removed out of these osteotomies, And we want to make sure you have a floor. And we collect all of them. Okay. And the most critical part is this. When we check against and we feel bone all along. Bear with me. Doing fine. Good. And, again, if you can see closely, zoom in as much as you can. Please, you can see that this buccal plate is still attached. It’s wide open. Okay. It’s one, and this is the second bite. Okay. Good. Now I’m going to take the black, plugs out and use the offset driver to seat these implants in all the way. There’s one. And we hold the implant together. Two. Okay? Good. And here. Alright. Now we cut the black healing plugs, and we will seat them here and here. Beautiful. Now we will remove this. We’ll need a collagen plug, and we will start packing these together. So as you can see the gap is only about two or three millimeters. Okay, that’s it. So whatever little bit of bone we got is more than enough to cover the shoulder of these implants. That’s all I want to use it for. I don’t need to graft because the area in between the implants will have the blood clot. So we are going to bridge the difference or that little gap with collagen plugs. Stay out for a minute here. And this I will use a continuous suture because it will apply the pressure a little bit more across without creating a a circulation compromise at the crest. Pad the area so that the bone that is in there over the shoulder of the implant doesn’t get washed off, the implant will integrate, it doesn’t need to have a barrier function in other words. It’s always not a bad idea to, put a couple of interrupted sutures so that your entire surgical site is not dependent on just one knot to stay secured. Ladies and gentlemen, almost there is one of that collagen plug. Good. And one more suture. And, of course, now that we need it to have a little bit of bleeding, it refuses to do so. And here we are. Careful where you’re pushing and just pull. Good. K. Retract the lip. And the reason why I’m using the inverted figure of eight is because this was an extraction socket, so I want the suture to be pulling the collagen plug down also as well as holding it in place. So I want the actual X of the figure of eight to be inside the socket rather than on top of it. Here we are, last suture. There you have it. The total time for a corticotomy, ridge split, and implant placement is basically what you’ve seen. Okay, we’re all set. So this is the split and the implants are engaging the unsplit bone and we are about four millimeters away from the mental foramen and from the mandibular canal, so there is no need for steroids. We have the three implants placed in the locations we want. That actually is a question that seems pretty straight forward, however, it’s pretty difficult to answer, without saying that we’ve done a few of those, so experience plays a role. The fact is that the osteotomies, they you can’t place them in too many locations. First, in this case, we had the socket of the first bicuspid. So that’s a given. That’s a very good starting point. In this in the second bicuspid, we have the vertical cut. Okay? And the vertical cut, as you saw, starts at roughly two millimeters to three millimeters from the distal wall of the socket of the first bicuspid. So if we place our implant roughly so it touches the end of the mesial cut, so you start at about two millimeters from that mesial cut, you’re going to be exactly within about three millimeters of the socket. So that places the two bicuspids like they would be naturally. So those two are easy. The difficulty was where to place the molar, implant. And the molar implant, basically, I backtracked from the back because I had done the calculations when I did the cuts, and I again placed it within the, bone flap itself by going two millimeters anterior or mesial to the distal cut. Now, alternatively, you could have had a stent. However, the difficulty with the stent is it doesn’t account for where you will have split the bone. It will place your osteotomies at the very thin crest, which can then be misleading. It may take you too lingual. Alright? And when you do the the split and you start moving buccally, those distances may change ever so slightly, and they can carry you into the wrong, locations. As you saw, I was worried about the location relative to the, roof of the submandibular fossa, and we checked, and we we weren’t in it. So you wanna be sure you have the right stance. The, four millimeter and four point five millimeter reamers were hand reamers. Those are, the quasi cylindrical ones that sort of expanded with one corner cutting only instead of two, like in the latch reamers. But they were mounted on an adapter, okay, that has a screw, top that would then make them adaptable to the latch handpiece because the maxilla prevents me from coming in and actually doing it by hand. So although it is still a hand reamer, it works like a hand reamer, in some aspects, but it’s drilling in full circle, but much more gently than a latch reamer. So that was, you know, I did change those. I don’t know if it wasn’t that clear. But the four millimeter reamer and the four and a half were both hand reamers on the, on the latch adapter. Well, the waiting, the healing of these implants in the split is actually, not significantly delayed because of the plateau design of the implant, okay? The implant is going to integrate by callus formation. So whether you have mobile or immobile bone initially, at the base it’s gonna heal at the same speed, provided that the patient’s chewing habits and other oral hygiene habits are not going to traumatize the buccal plate. So the short answer is I would wait the same amount of time that I would wait for a type four bone, which is three to four months. From Boston, thank you again and until tomorrow, four o’clock. See you. Bye bye.